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Archive for the ‘Nursing’ Category

or rather the people in the iron lungs…

Spending my afternoon off doing the usual things; as I was folding laundry watching one of my favorite quirky comedies, Bubba Ho-tep, it brought to mind an interesting bit of medical history.. the era of the Iron Lung, or negative pressure ventilator.

There is a brief scene at the beginning of the film, which is set in “Shady Rest Home” in rural Texas..  In this scene at the beginning of the film, one of the nursing home residents, who is a bit of a thief, steals the glasses from another resident, an elderly woman who is imprisoned in an iron lung.

iron lung display at the Sacramento Medical Museum

iron lung display at the Sacramento Medical Museum

This is an interesting footnote to the Iron Lung – the one we don’t often hear about – the fact that several Americans are still encased in this iron maiden of artificial respiration.  According to the most recent statistics available (2004) there were more than thirty people still living in iron lungs in the USA.  (Some sources cite 19 people in Houston alone – in 2009.)

Not everyone needed to use iron lungs for years – in fact, many of the children and young adults stricken with polio recovered after several months, and went on to live normal (ventilator-free) lives.  But for others – the iron lung became a life-long condition.  Here are some of their stories..

“28 years in an iron lung” – interview with Joan Herman – Mark Finley, April 1976, Ministry Magazine

Soon, as these  few elderly patients pass away – the iron lung, the relic of early life support technology will be forgotten into the pages of history; remembered only by history buffs such as myself, in a few scattered photos and the backrooms and storage sheds of obscure museum archives.

The negative pressure ventilator aka ‘tank respirator’ worked exactly as it sounded – patients were placed into the small cylinder, with their chests and lower bodies enclosed as the machine applied negative pressure (think of vacuüm suction) to make the patient’s chest physically rise for inspiration. While iron lungs were invented in the late 1920’s, they became popularly known in the decades following their invention due to Poliomyelitis.

http://www.youtube.com/watch?v=jywAB0Wio-Y

The iron lungs became critical life-saving devices for large numbers of people, especially children (who were more affected) during the polio outbreaks of the forties and fifties, and were one of the most visible images of medical technology / modern medicine of the era.

Martha Mason, one of the most well-known of the modern-day iron-lung reisdents published a memoir entitled, “Breath” of her sixty-year experience in 2003.  It’s a great glimpse into a full and amazingly rich life lived despite these handicaps.

http://www.youtube.com/watch?v=EhRSRuKaAv8
Another Iron Lung resident, Diane Odell made headlines after she died during a power outage, which caused her iron lung to stop working. (This is an on-going problem for people living on life-support apparatus in their homes according to a 2009 article.)

http://www.youtube.com/watch?v=zZfP2X6wT5Q

Related stories:

Bangor man living with effects of Polio still  in Iron Lung.

Polio: The Iron Lung

University of Virginia on-line Iron Lung Exhibit

We are all welcome here” – fictionalized biography of Pat Raming.

The Sessions: Life in an iron lung – movie about man in Iron Lung.  Click here to read an interview with the actor.

Mark O’Brien – the real life behind the man in the sessions.

Interview with British man from 2004, BBC living in an iron lung.

Life in an iron lung – Paul Berry

Not even an iron lung” – Laurel Nisbet, who became a preacher in Jehovah’s Witness religion

Iron lung in Dallas – Star-News article, 1976

The Emerson Respirator – article brief from Anesthesiology, April 2009

A practical mechanical respirator, 1929: the ‘iron’ lung.   Meyer, J. (1990).  Annals of thoracic surgery.

Reading periscope for iron lung patients

An improvised iron lung – 1956 letter to the British Medical Journal

Negative pressure ventilation in the treatment of acute respiratory failure: an old noninvasive technique reconsidered. – 1996 article on potential modern applications for the iron lung.

Iron lung versus conventional mechanical ventilation in acute exacerbation of COPD. – a 2004 article comparing use of iron lung (negative pressure ventilation) with more invasive positive pressure mechanical ventilation.

More about Martha Mason:

Documentary on YouTube

Book review of Breath – at the Washington Post

“Martha in Lattimore”

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Best of both worlds

It looks like sometimes I can have the best of both worlds; spending time with my patients (and hopefully helping to improve their lives/ restore wellness) while having the opportunity to travel, to interview and observe surgeons from around the world.  It’s been a difficult balance because it’s hard to find nurse practitioner positions that allow the sort of flexibility I need to continue my other (pursuits?)

Nurse Practitioner/ Medical Writer?

I love being a nurse practitioner but I also see myself as a writer so it’s hard to relegate my journalistic endeavors to the little corner known as ‘hobby’.   In fact, I feel that my travels are an essential counterbalance to my daily practice in nursing and cardiothoracic surgery.  My travels, particularly into cardiothoracic surgery in other locations – give me grounding and perspective.  Otherwise, without continuous effort – things can become too routine, too “by rote”.  While it’s critical to stay-up-to-date in medicine; it’s also crucial to continue to think about what we are doing – to get away from the ‘cookbook medicine’ of algorithms and protocols every so often.

Is it all about the protocol?

Protocols and algorithms based on ‘evidence-based practice’ are highly useful but they aren’t the only consideration when it comes to patient care.  Patients are individuals – and care needs to be individualized to each person’s situation and needs – which is where protocols often fail.

So it’s also helpful to see other variations in practice.  Sometimes the ways that other people/ hospitals/ groups practice isn’t just different; it’s better.  Maybe it’s not better for every situation, and maybe it shouldn’t replace the current standardized protocols at your hospital – but it might fit the needs of some of your individual patients.

But you have to be more that open and receptive to the idea of variations in practice – you have to be aware of different practices.   While conferences, lectures and publications may present and discuss different practices, the best way to learn about and see different practices – is to go there.  

But how/ when can a working nurse practitioner find the time to see different practices?

Locum tenums

Both, now I have found a way to see and experience this on both a national and international level.  I’ve begun practicing as a locum tenums (or temporary) nurse practitioner at different facilities in the United States.   I work for a few (or several) months at different hospitals and practices across the USA – giving me a spectrum of care within a basic framework of American medicine; from rural or small-town surgery programs to big-city/ metropolitan or academic settings.

In between assignments – with careful planning and budgeting, I can continue my international travels.. So far it seems ideal..

fwy bw

Coming to a city near you..

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Long time readers (and former patients) will be familiar with my aspirin mantra but now Medscape has published a CME course by Dr. Desiree Lie for health care providers in primary practice, general surgery (and other areas that may not be familiar with post-cardiac patient recommendations.)  As I may have mentioned before, in cardiac surgery – we routinely start aspirin in our patients prior to bypass surgery.

Don’t stop Aspirin before surgery

I’ve converted the CME course, Don’t stop Aspirin before surgery into a pdf – but if you want credit – you will have to go to Medscape and log in.  (For everyone else – it’s a nice read – and explains the importance of continuing aspirin in patients who are taking it for “secondary prevention” or are at high risk of cardiovascular events.

That’s because the complications of discontinuing aspirin therapy in these patients are WORSE than the minor risk of bleeding.  (Bleeding issues for most patients taking aspirin are fairly minor.. Now, clopidogrel (Plavix) and prasugrel (Effient) are another story!)

Wait a second… What’s secondary prevention?

They way to think about secondary prevention is “closing the barn after the cows are loose,” as one of my colleagues explains it.  This means that Aspirin has been prescribed to these patients after something has already happened – like a stroke, a heart attack, stents or cardiac surgery.  So in these patients – secondary prevention can be thought of as preventing a second event or further complications from a disease process we already know about.

Now, patients that are at high risk for cardiovascular events like diabetics or people with other kinds of blockages (peripheral vascular disease, renal artery stenosis) haven’t had a heart attack yet – but we think that they are at a high risk of this happening – so they take aspirin to prevent this (primary prevention).

In people who are at low or moderate risk – low cholesterol, nonobese, normal glucose, nonsmokers:  these people may take aspirin, but (probably not prescribed) and it is safe for them to discontinue aspirin before surgery.

But in the first two classes of patients (secondary prevention group/ high risk group) – stopping aspirin may actually INCREASE the risk of having a heart attack, stroke or other thrombotic event during surgery.  But if you are having surgery – be sure to check with your cardiologist or cardiac surgeon before.  Don’t rely on your PCP or general surgeon (it’s not their area of expertise) and they may not be up-to-date on the latest recommendations [hence the continuing education course].

A new chapter at Cartagena Surgery: the DNP program

Nashville, Tennessee

Back in Mexicali, MX after spending a week in Nashville, Tennessee for the start of my doctoral program in nursing.  It felt weird to be back in Nashville after so long (I lived there while attending Vanderbilt for my masters degree).  It was surprising how much had changed – the medical center and the university campus just continue to grow and grow!

But then again – with 70 people in the Fall 2012 DNP class, I guess it’s no surprise that the campus is growing.  About 15 of us are full-time students.  I’ll be heading off to Bogotá in a week to start some specialized study there – so between the DNP program and Bogotá – I might be posting a bit less often.

Fall 2012 class for DNP (doctorate of nursing practice) at Vanderbilt University

The DNP is a new degree that takes the place of the DNSc (doctorate of nursing science) or the ND (nursing doctorate) – depending on who you ask.  I know that sounds like alphabet soup to many people, so I’ll post some more information about the degree soon.  But the main thing to think about when thinking about doctoral degrees – is the focus behind the degree.

PhD – or a doctorate in Philosophy are Research degrees. (research with a capital ‘R’)  Think about labs, nursing theories and hard-core research..so think ‘nurse-scientists’.. I tell people to picture a nurse with a beaker and a bunsen burner.. Not entirely accurate but a good mental picture.

DNP – is a clinical doctorate – used to translate much of this research into improved clinical practice.  Clinical, clinical, clinical.. This is the degree for people who are still planning on working in the clinical (hospital-based or clinic-based) setting, seeing patients.  The courses in this program are designed to promote evidence-based practice – or using all of that research that our nurse-scientists (and other researchers) are publishing.

So the hope is that the DNP will be able to improve the care of patients by creating protocols and such.  As it is still a fairly new degree – there is currently a lot of cross-over among PhD trained nurses, and I suspect there always will be – it’s more a matter of preference in what a nurse wants to focus on during her doctorate education. (So don’t be surprised if your nurse practitioner has a PhD.)

There are still plenty of doctorates in education and other fields as well like administration because it takes all types of nurses to serve as faculty, deans of educational programs, and hospital administrators.

There are even a few doctorate of nursing science programs left – in Louisiana and Puerto Rico..

Now I apologize because this is a simplistic explanation that leaves out a lot of nuance but I’ll provide more information soon.  But now, I better get back to the books!

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I wanted to post some more information and links for people like myself, who are interested in a more global view of the profession.

On Saturday, several speakers discussed the state of advanced practice nursing and the role of the Nurse Practitioner in different countries.  All of the speakers were members of the International Council of Nurses, an organization created to help develop advanced practice nursing roles around the world.

Unfortunately, as is often the case at these conferences – there was no Latin American representation (even though there are several strong doctoral programs and advanced nursing in several Latin American countries – if not the actual NP role, per se.)  But that’s my bias, since I have a strong interest in both my profession and Latin America. (Be careful, Professor, given the opportunity – I just might not leave.. But alas!  No NPs in Mexico yet..)

Of course, none of the European NPs (outside of the UK) were present either, so if you want to be more involved with these nurses you have to attend the ICN or other Region – Specific* conferences.

The actual speakers were interesting and engaging and included speakers from the UK, Singapore, Canada and Australia.  (I was taking notes as fast as I could, so I didn’t manage to get complete titles for everyone, and I apologize).

Singapore

Madrean Schober at the Alice Lee Center for Nursing Studies presented information about nurse practitioners in Singapore.  As the role is quite new, she is a visiting fellow who is helping the National University of Singapore develop and implement this role.

In Singapore, the advanced practice nurse is a legally protected title, meaning that people have to meet rigorous standards to use the title, with penalties enacted for people who appropriate the title wrongfully.  This is similar to the USA but an important distinction that doesn’t apply in many countries.

The title and role of the APN is a hybrid of what we traditionally think of as both the NP and CNS (clinical nurse specialist) roles.

The first training programs were started in 2003 – and now consists of a 24 month program, with over 150 graduates so far.  The majority of graduates function in in-patient (or hospital-based) roles with the majority in intensive care units and mental health facilities.

In contrast to many countries, the push for the development of the APN role wasn’t due to an acute need, it was a deliberate effort to try to retain Singapore nurses and prevent a ‘brain drain’ as nurses from Singapore look for opportunities in other countries.

Advanced Practice Nursing in Singapore

Singapore Nursing Board

* Since the AANP is fairly region specific to the United States.

South Africa

Nelouise Geyer, CEO of the Nursing Education Association talked about the state of nursing in South Africa which is currently undergoing several changes in the classification of different levels of nursing.  There is no formally recognized NP role at present but there are advanced practice nurses such as midwives, clinicians in primary care and wound care specialists.

I found the new proposals for nursing classifications to be somewhat confusing and overly complicated as an outsider, but she was presenting a lot of information in a very short time.

Canada

Christine Buckley from Ontario presented information about Canada.  I find the situation in Canada to be quite encouraging despite having the usual growing pains with licensure requirements being fairly inconsistent across the provinces.  Despite being one of the newest countries to add nurse practitioners to the health care provider team – Canada has come on strong – with over 3400 NPs in just a few short years. (There were only 1129 in 2006).  Nurses in Canada have initiated a very successful (and catchy) slogan to encourage public interest in nurse practitioners, called “It’s about time!”

It’s about time!

Of course, they stress the use of NPs in primary care, but as the use of NPs grows in Canada – hopefully they will start to highlight some of the great things we do in specialty care too..  (They recently recognized a “NP in Anesthesia” role in British Columbia so it’s definitely on the way.)  They have done such an incredible job in just a few years – so kudos to our neighbors up north.  (As a Dalhousie graduate [non-nursing], I am particularly proud.)

Australia

I didn’t get the name of the Australian nurse practitioner (couldn’t write that fast!) but she did an excellent job outlining the history and the current state of the NP in Australia.  In a country of 22.3 million people, there are currently 740 nurse practitioners.  Unfortunately, only 71% (436) of these NPs are able to find work as a nurse practitioner due to a multitude of issues.

However, in the last few years, the NPs in Australia have been able to achieve national registration and well as reimbursement for their services.  (Prior to 2010, patients had to pay out-of-pocket to see an NP.)

United Kingdom

Jenny Ashton talked about the roles of the NPs in the United Kingdom, and explained that due to a lack of formal registration, there is no accurate count of the numbers of NPs currently practicing there.  While there is little consistency across the UK in general, she stated that both Wales, and Scotland have a more formalized process.

While there remain multiple barriers for NPs practicing in the UK, one of the biggest obstacles has already been overcome: NPs in the UK have full prescribing rights – which is something that not even all states in the USA have.

Unfortunately, from her presentation (and this is my interpretation) it sounds like one of their biggest obstacles is the Nursing Council itself which seems uninterested in examining (and resolving) the issues around standardizing educational requirements, formal title protection and registration and other policy issues.  Luckily, it sounds like the medical colleges are more than interested in playing a role in the continued development of APNs.  (Of course, that can be a double-edged sword as well.)

Hopefully, we’ll hear more news about our other nursing colleagues around the world soon – and maybe I’ll be able to attend one of the ICN conferences in the future (and be able to report from there.)

Future of NPs

In my mind, one of the biggest obstacles to the implementation and utilization of the nurse practitioner in other countries is lack of understanding of the role.  In many places, this is due to the perception that NPs can only function in a primary care role.  (This is extremely limiting in countries where there is no shortage or even an overflow of primary care physicians.)  In my [very limited] experience and interactions with surgeons in both the USA and abroad – this obstacle is quickly diminished as surgeons see the utility of having someone trained to handle all the ‘medicine’ aspects of surgical patients, so they can spend more time operating, and not worrying about managing co-morbidities or post-operative care.  This perception has been validated by several of the papers we’ve seen (and talked about before) from Germany, Japan and other nations where the surgeons themselves are trying to import the NP position to their home countries after working with NPs during their fellowships or other training in the United States.

References / Additional Information

The ICN / Nurse Practitioner & Advanced Practice Nurse Network – This organization is for the promotion and support of the development of the APN/ NP role internationally.  The above link takes you to the membership information page.  Membership is free.

The ICN website also contains information on the development of the NP role in other countries (Thailand, for example), a global definition of the NP role, and information about other nursing conferences worldwide. I recommend a look at the FAQ page which explains that the NP role exists (or is in development) in over 70 countries.

This is a link to the definition of the NP role in Spanish for all my friends/ colleagues and everyone else I’ve met who wonders what my job really is (for when my own explanations have them questioning my Spanish language abilities)..

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As many of my readers here at Cartagena Surgery and my sister sites know – I came to the National Conference to present a poster on “Use of Social Media to Promote Specialty Practice.”

presenting my poster at the 27th AANP conference

The poster is about how the thoracic surgery website brings together thoracic surgery professionals (surgeons, NPs, PAs, Respiratory therapists) from around the world and how it connects patients with credible but easily understandable information.

While I was there – I got the chance to meet some of the other presenters.

Tulay Cakiner-Egilmez, ANP is an ophthalmology nurse practitioner at the Boston Veteran’s Administration.  She was presenting a poster talking about performing eye exams and screening for glaucoma and other eye conditions.   My poster was next to hers, so we were able to talk in-between visitors. She’s been a nurse practitioner for three years, but has worked in the field of ophthalmology for over 25 years so she has a lot of great experience!

Tulay Cakiner-Egilmez, ANP

Debbie Kantor, MSN, ARNP and Lt. Sherrin Whiteman, MA from Hero, Inc. had a great presentation so I wanted to be sure to mention them since they may be a good resource for our readers.   They were talking about “Health Education to Reduce Obesity” and their mobile patient / community health education program.

Sherrin Whiteman, MA and Debbie Kantor, ARNP, MSN of Mobile Hero provide health education to reduce obesity

They run a pretty cool program with a nurse practitioner, a fitness instructor and other health educators who travel around to different communities to provide people with information about fitness, exercise, diet and healthy eating to prevent/ reduce obesity and promote wellness.

Brenda Reed, DNP, FNP-BC, RN presents information of genetic screening and referrals for Ovarian and Breast Cancer

Dr. Brenda Reed, DNP, FNP-BC, RN is an absolutely delightful nurse practitioner who is on the nursing faculty at Texas Christian University (Harris College of Nursing and Health Sciences) presented a wonderful poster on the genetic screening for breast and ovarian cancers.  Not only was the poster visually stunning, but she presented a lot of great information.  I really enjoyed talking to her.  (I’m not sure if they give awards at the end of the conference for ‘best poster presentation’ but my bet is on Dr. Reed.)

I ran into one of my favorite professors from Vanderbilt. Dr. Joan King, PhD, ACNP-BC, RN (almost literally – I was a bit lost in thought at the time).  She was (and is) the director of the acute care nurse practitioner program.  She was lecturing at the conference, and surprisingly, remembered me immediately.  (It’s been more years than I care to admit and the Vanderbilt School of Nursing is a large school so I was very flattered that she recognized me.)

Lastly, I was thrilled to meet Dave Mittman, PA.  He’s the founder of Clinician 1 which is an online website/ community for nurse practitioners and physician assistants.  He’s really down to earth and charming in person, and didn’t seem to mind taking a few moments to talk to me.

with Dave Mittman, PA and founder of Clinician 1

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Orlando, Florida –

AANP President, Angela Golden addresses a packed house

The new AANP president, Angela Golden was here to cut the ribbon and officially open the conference.

at the ‘Spanish for Nurse Practitioners” course

Away from Mexicali this week for the 27th annual American Academy of Nurse Practitioners (AANP) National Conference.  It’s been a fun couple of days; meeting and talking with nurse practitioners from several different countries and talking about issues in nursing.

The Nurse Practitioner  – International

Wedsnesday, I sat in on an international NP meeting with NPs from Canada, the UK, and New Zealand.  There was also a NP who is working in India, trying to promote advanced practiced nursing.  There are several more sessions on the role and status of NPs in other countries – so I will be updating this section over the next few days.

NPs are pretty new to the scene in all of these countries –

the UK recognized its first fifteen NPs in 1991, and continues to struggle with role recognition and role protection there.  The moderator of the meeting, who is one of the original British NPs explained that there is no restriction or requirements for a nurse to call themselves an NP,  whether they have qualified as an NP or not.

New Zealand first recognized NPs in 2003, and currently boasts 103 formally recognized nurse practitioners.  Currently, New Zealand has no established nurse practitioner specific master’s program or clinically based requirements, so that will be one of their growing pains..

Canada – is the newest of the bunch – but appears to leading the way – with Family nurse practitioners and a new acute care nurse practitioner program.   Unfortunately, much like the United States – each individual province has different licensure requirements (which are time-consuming and expensive).  Unlike the USA, despite a huge need for NPs – there are few jobs available due to the relative lack of private employment opportunities.  (The majority of positions are government-funded.)

(There are NPs in other parts of Europe, but none of their representatives were present.)

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Today we are talking to one of my colleagues – Ms. Trisha Hutton.

Ms. Trisha Hutton, CRNFA

Ms. Trisha Hutton, CRNFA, ACNP (student)

Trisha is a certified registered nurse first assistant (CRNFA) .   She performs procedures in the operating room such as endovascular saphenous vein harvesting (EVH) for bypass surgery, and assists in other aspects of surgery, such as suturing, retraction and tissue dissection.

  Years in the operating room:   16

  Years working in cardiac surgery:  8

We’re talking to Ms. Hutton today about her current career and her developing role as an acute care nurse practitioner in cardiothoracic surgery.   Ms. Hutton is currently pursuing her master’s degree for certification in acute care, and will be part of a small but growing sub-specialty of acute care nurse practitioners in surgical practices.

As we’ve discussed during past posts; in the midst of a primary care crisis, advanced practice nurses such as nurse practitioners have moved to the forefront of the health care arena.  While NPs have worked (successfully) in this role since the creation of the specialty in the late 1960’s – the efforts of NPs in this (and other) roles are just now being recognized.

However, for nurses like Trisha Hutton, the increasing recognition (by surgeons) of the utility of nurse practitioners IN and OUT of the operating room is equally important.  So it’s important that nurses like Ms. Hutton receive the exposure to the public that may not always be aware of their role behind the scenes in caring for patients undergoing surgery.

What prompted you to return to school to become a nurse practitioner?

 “I felt like something was missing.  It was like chapters were missing from a book,” Ms. Hutton states, explaining that while she loves her current role, assisting and caring for patients in surgery – she wants to expand her role to encompass the care of patients outside of the operating room; from admission to discharge.

Ms. Hutton (pictured on the right) in the operating room

What drew you to cardiothoracic surgery, specifically?

I have always been interested in vascular surgery, and had been trained by and a vascular surgeon (Dr. Mark Donnelly) who I have worked closely with for many years.  When Flagstaff Medical Center started talking about beginning a heart program, I was immediately interested, and Donnelly encouraged me to be involved in it.  Also, because of our elevation (7000 ft), there was controversy about the success of our program, and that challenge excited me.

How do you see your role evolving after graduation?

To have the ability to continue my care to patients outside of the operating room.  I am looking forward to the opportunity to meet patients pre-operatively, participate in their diagnosis, operate on them, then continue their care through discharge.

Where do you see yourself in five years?

I hope to continue practicing within the CT and vascular specialty, and be comfortable within my expanded role.

Who are your role models?

I began as nurse in the operating room 16 years ago, and was instantly attracted to the vascular specialty.  I developed a relationship with a surgeon named Mark Donnelly, a very respected and talented General/Vascular surgeon.  When I decided to become a RNFA, he supported me, acted as my preceptor, and taught me how to operate.  As mentioned earlier, when word of a heart program started, he encouraged me to join the heart team.  That was a bitter-sweet decision for me….learning CT surgery has been a fantastic choice for me and has opened many doors, but it meant leaving a surgeon that I truly enjoyed operating and spending my day with.  He has been such an important role model for me and “life” coach (advice ranging from career to parenting!!), and I still miss working with him. More recently, our current heart surgeon Dr. Steve Peterson has been an important role model to me.  I joined cardiac surgery with good assisting skills, but he has pushed and challenged me even more.  He continues to test me daily, teaching me the finesse of cardiac surgery.  Without him I would not be  successful within this specialty, and I would never have considered continuing my education.  He has given me endless opportunities, pushed me to grow, and I am very grateful for him.

How do you see the nurse practitioner role in comparison to other peri-operative roles?  Do you think NPs provide any unique perspectives or contributions to surgical care?

NP’s absolutely offer unique contributions to surgical care!  Especially if they have had perioperative experience prior to becoming an advanced practice nurse.  I believe continuity of care is an important factor in delivering high quality care to our patients, and if the NP can follow her patient into the operating room, that continuity of care can be achieved.  They see and experience first hand what occurs during surgery, which can aid in their post op management.

For instance, if closing an aorta post AVR and the aortic tissue is particularly fragile, the NP will know that post op blood pressure management will be even  more critical. If a different practitioner had been operating, that concern may not be communicated adequately.  The surgeon who practices with a NP First Assistant can feel at ease knowing that both HIS needs and the patients’ needs will be met.  The NP who is familiar with the patient will know just what the surgeon will want in the operating room, will have appropriate equipment, supplies, support staff etc available, therefore making the patients’ surgical experience smooth and uneventful. A first assistant that does not have that relationship with the surgeon or patient (ie family practice MD or TechFA) cannot offer that unique service.

Nurse Practitioners in the operating room?  Current issues and controversies

While this seems like a natural and normal progression for many nurses and nurse practitioners within the field – it isn’t as obvious to people outside the profession.  Many people including human resources personnel, staffing companies and the surgeons themselves have pre-conceived notions that exclude nurse practitioners, even those with extensive operating room (peri-operative) experience from assisting in the operating room.  That role is often exclusively assigned to Physician Assistants, often to the detriment of our profession, our nursing colleagues and the patients.

In fact, in this recent statement and study on the role of surgical assistants (2011) only mentions nurses as assistants as a side note.  It fails to recognize the different levels of qualifications (ie. a certified registered nurse first assistant (RNFA) versus a surgical technician (with weeks to months of formalized training).

Now, with the adverse economy, and changes in medicare regulations, nurse practitioners face even more competition for the operating room; the disenfranchised primary care physician.  In several of the facilities where I have worked in the past; more and more of these physicians were taking an active role in assisting in surgery.  These doctors, often primary care doctors ‘moonlight’ in the operating room as a way to augment their salaries.  Conversely, while these physicians had the least amount of surgical training, they were afforded the most reimbursement for their intra-operative role.    This array of peri-operative assistants has led to a wide range of skill sets in this patient care role with little research or comparison of effectiveness of these positions.

Ideally, the best ‘surgical assistants*’ would be patient care roles that encompassed the entire patient surgical experience from pre-operative evaluation to patient discharge, which is the spectrum of both nurse practitioners and physician assistants.  But only nurse practitioners can bring a holistic, patient-centered approach to this

* The ‘surgical assistant’ title like surgical technician/ technologist has also been designated to another career entirely, with similar focus.  However, in this post, we are using the term generically to refer to any individual (NP, RNFA, PA , MD or technician) who acts as an assistant to the surgeon intra-operatively, and performs procedures under the supervision of the attending surgeon.

References/  Literature surrounding nurse practitioners in the Operating Room

Hodson D. M. (1998).  The evolving role of advanced practice nurses in surgery.  AORN J. 1998 May;67(5):998-1009. Erratum in: AORN J 1998 Jun;67(6):1102

Pear, S. M., & Williamson, T. H. (2009).  The RN first assistant: An expert resource for surgical site infection prevention.  AORN, 89(6); 1093 – 1097.  No free full text available.
Schroeder JL. (2008).  Acute care nurse practitioner: an advanced practice role for RN first assistants.  AORN J. 2008 Jun;87(6):1205-15.
Wadas T. M. (2008).  Expanding the scope of acute care nurse practitioners with a registered nurse first assist specialty.  AACN Adv Crit Care. 2008 Jul-Sep;19(3):261-3.

Wadlund D. L.  (2001).  Graduate education: the perioperative nurse practitioner.  Semin Perioper Nurs. 2001 Apr;10(2):77-9

Zarnitz P, Malone E.  (2006).    Surgical nurse practitioners as registered nurse first assists: the role, historical perspectives, and educational training.  Mil Med. 2006 Sep;171(9):875-8.   No free full text available.
More about the Registered Nurse First Assistant (RNFA) role from the Association of peri-Operative Nurses (AORN).

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